NAIROBI — A key phrase heard at the Nairobi Summit on ICPD25 this week, a global summit focused on sexual and reproductive health and rights, was “unfinished business.”
It referred to stalled progress on a visionary document created 25 years ago at the International Conference on Population and Development in Cairo that called for “all people to have access to comprehensive reproductive health care, including voluntary family planning/contraception and safe pregnancy and childbirth services.”
While progress has been made in many of these areas, such as reducing maternal mortality, many people still lack access to good health care, contraceptives, and information.
Each day, about 810 mothers die from preventable causes related to pregnancy and childbirth, an estimated 232 million women in low- and middle-income countries that want to prevent pregnancies aren’t using contraceptives, over 200 million females are victims of female genital mutilation, about 12 million underage girls are married each year and 1 in 3 women worldwide have experienced physical or sexual violence.
During the summit, which was hosted by the United Nations Population Fund and the governments of Kenya and Denmark, the Nairobi Statement on ICPD25 was released. The non-binding statement outlined the goal of eliminating preventable maternal deaths, eliminating gender-based violence and harmful practices, such as child marriage, and meeting the needs of people who want contraceptives but aren’t using them — all by 2030.
But these lofty goals aren’t cheap. Research released this week showed a $222 billion gap in funding to effectively accomplish these targets in priority countries over the next decade.
Summit participants discussed the ways to close this gap — agreeing the approach needs to change.
“We need to think boldly and we need to think differently,” said Muhammad Ali Pate, director of the Global Financing Facility.
“In the long-run, family planning is cost-saving. Family planning will generate savings many times greater than the expenditure required to meet these goals.”— John Stover, founder, Avenir Health
Costs and gaps
According to findings released this week by UNFPA and the Johns Hopkins University, in collaboration with the University of Victoria, University of Washington, and Avenir Health, it would cost about $264 billion to effectively accomplish these targets in priority countries.
Read more from the summit and SRHR
To break this down, eliminating maternal mortality would cost $115.5 billion, eliminating the unmet need for women who want contraceptives but aren’t using them would cost $68.5 billion, eliminating female genital mutilation would cost $2.4 billion, eliminating child marriage would cost $35 billion, and eliminating physical and sexual violence would cost $42 billion.
Donors are expected to only provide 16% — or $42 billion — in official development assistance on these goals over the next decade, according to UNFPA, leaving a $222 billion gap.
Looking at trends in spending, ODA for sexual and reproductive health and rights peaked at $11.3 billion in 2017; but 70% of all donor funding that year was dedicated to tackling HIV, and family planning received only 9%, according to research conducted by Dr. Marco Schäferhoff, managing director of Open Consultants, commissioned by the World Health Organization’s Partnership for Maternal, Newborn & Child Health.
Overall, the spending devoted to sexual and reproductive health and rights as a percentage of total health aid is on a downward trend. It dropped from 52% in 2011 to 42% in 2017, Schäferhoff said.
“This means the funding for [SRHR] did not increase at the same growth rate as donor funding for other health areas,” he said.
There is also concern funds could decrease further.
“We are facing an uncertain economic future, the IMF has just downgraded the growth forecast again,” Schäferhoff said. There is a risk that official development assistance budgets will be cut amid slower growth, he said.
In lower-middle-income countries, donor funding only accounted for 3% of health expenditures whereas it still accounts for 30% in low-income countries, he said. Governments in low-income countries spent about $1.1 per capita on sexual and reproductive health and rights in 2016, whereas the cost of a package of interventions on these issues is estimated at $13 per capita, he said.
Governments will need to take ownership over filling in these gaps in funding, said many speakers at the summit.
“We cannot and will not wait around for donor funding,” said Macharia Kamau, principal secretary of Kenya's Ministry of Foreign Affairs. “Those countries that are transforming their realities are recognizing that they have to raise their own resources, pull themselves up by their own bootstraps and get to the business of investing in their own health, education, and food security.”
In order to convince governments to spend more on sexual and reproductive health, advocates should frame the conversation around “investments” rather “costs,” many of the speakers agreed.
“In the long-run, family planning is cost-saving,” said John Stover, founder of Avenir Health. “Family planning will generate savings many times greater than the expenditure required to meet these goals.”
“We need vibrant institutions and civil society to advocate and make governments accountable to their commitments. They push governments to make the right decisions — the tough decisions when it comes to women’s health.”— Maria Antonieta Alcalde, director of Central America and Mexico, Ipas
According to a report released last week by UNFPA, some ways to domestically increase finances include progressive income taxes, earmarked taxes, and health insurance pre-payments, while making efforts to limit out-of-pocket expenses.
Global momentum around countries adopting universal health coverage also has the potential to increase financing available for sexual and reproductive health and rights, according to summit participants.
“It will be critically important for donors to include [sexual and reproductive health and rights] as an integral part of their UHC efforts,” Schäferhoff said.
But even when funding is available, some governments have issues spending — or absorbing — those funds because of lack of technical capacity, said Dr. S.K. Sikdar, commissioner in charge of immunization in India’s Ministry of Health and Family Welfare.
“For example, the southern states of India are very good, but the northern states are where the challenges are, where the absorption rate is not as high,” Sikdar said.
Governments can also encourage private sector investment by working to de-risk deals, said Hilde Klemetsdal, director for human rights, democracy and gender equality at Norway’s Ministry of Foreign Affairs. One example of this is through volume guarantees, she said, that can help cut the cost of contraceptives.
Effective investments, funding civil society
Funding should go to the most effective interventions, said Maria Antonieta Alcalde, director of Central America and Mexico at Ipas.
“For example, we know that safe and legal abortions are a wise investment,” Alcalde said. “Women are entering hospitals to be treated for complications from unsafe abortions and the financial impact this has on the health system is huge.”
Providing flexible funding to build up local institutions and civil society in low- and middle-income societies is also crucial, conference attendees said.
“We need vibrant institutions and civil society to advocate and make governments accountable to their commitments,” Alcalde said. “They push governments to make the right decisions — the tough decisions when it comes to women’s health.”
This should include funding women’s organizations working in frontline health work, said Katja Iversen, president of Women Deliver.
The Global Financing Facility is also credited as an “important new mechanism” for funding reproductive health programs. Its blended financing model works to support countries around national priorities on nutritional and health issues for women, children, and adolescents. Each dollar invested in the GFF Trust Fund links to several sources of funding, including private sector resources, financing from the World Bank’s International Development Association and the International Bank for Reconstruction and Development, as well as government resources.
“There are efficiency gains when you align around country resources and find ways to reduce some of the issues of waste,” said GFF’s Ali Pate.
Overall, of the commitments made at the summit, only 6% were focused on mobilizing financing.
Some of the top commitments include Norway’s pledge of $1.2 billion, the U.K.’s pledge of $546 million, the European Commission’s pledge of $31 million, Germany’s pledge of $22 million, and Denmark’s pledge of $15 million.
World Vision pledged to mobilize $7 billion, Plan International pledged $500 million, the Ford Foundation pledged $78.4 million, Laerdal pledged $65 million, and the Children’s Investment Fund Foundation pledged $75 million.